Delirium and pulmonary embolism in the elderly

Pulmonary embolism or COVID-19 pneumonia? A case report

Pulmonary embolism (PE) is the most severe clinical presentation of venous thromboembolism (VTE), which can be challenging to diagnose due to its non-specific symptoms. The overlapping clinical symptoms of Coronavirus disease 2019 (COVID-19) and PE may make distinguishing between the two difficult. Thus, the diagnosis of PE may be delayed or missed, with grave consequences for the patient's outcome and safety. We herein present the case of a 63-year-old Iranian female admitted to our hospital showing symptoms of delirium superimposed on dementia. Soon after her admission, she developed a fever and respiratory symptoms. However, overestimating the likelihood of COVID-19 pneumonia and attributing the patient's symptoms to this disease led to a delayed diagnosis and treatment of pulmonary embolism, resulting in the patient's death. During the COVID-19 pandemic, a high index of suspicion is required for the timely diagnosis of PE, especially in patients with identifiable risk factors. This is specifically true for older patients who cannot express their symptoms due to neurocognitive disorders.

Neurological Consequences of Pulmonary Emboli in COVID-19 Patients: A Study of Incidence and Outcomes in the Kingdom of Saudi Arabia

Pulmonary embolism (PE) is a significant consequence that is becoming more common in COVID-19 patients. The current study sought to determine the prevalence and risk factors for PE in a study population of COVID-19 patients, as well as the relationship between PE and neurological sequelae. The research also sought to analyze the consistency of neurological examination and imaging techniques in detecting neurological problems. The research comprised a total of 63 individuals with COVID-19. The incidence of PE in the study group was 9.5% for smokers, 23.8% for obese patients, 33.3% for hypertensive patients, and 19% for diabetic patients, according to the findings. After adjusting for possible confounders such as age, gender, BMI, smoking, hypertension, and diabetes, a logistic regression analysis indicated that the probabilities of having neurological complications were 3.5 times greater in individuals who had PE. In conclusion, the present study highlights the high incidence of PE among patients with COVID-19 and the association between PE and neurological complications. The study also emphasizes the importance of a thorough neurological examination and imaging studies in the detection of neurological complications in patients with PE.

Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.

Delirium Severely Worsens Outcome in Patients with COVID-19-A Retrospective Cohort Study from Temporary Critical Care Hospitals

Delirium is a sign of deterioration of homeostasis and worse prognosis. The aim of this study was to investigate the frequency, risk factors and prognosis of delirium in patients with COVID-19 in a temporary acute setting hospital. A retrospective cohort analysis of data collected between October 2020 and February 2021 from two temporary acute care hospitals was performed. All consecutive hospitalized patients ≥18 years old with COVID-19 were included. An assessment of consciousness was carried out at least two times a day, including neurological examination. Delirium was identified through retrospective chart review according to DSM-5 criteria if present at least once during hospitalization. Analysis included 201 patients, 39 diagnosed with delirium (19.4%). Delirious patients were older (p < 0.001), frailer (p < 0.001) and the majority were male (p = 0.002). Respiratory parameters were worse in this group with higher oxygen flow (p = 0.013), lower PaO2 (p = 0.043) and higher FiO2 (p = 0.006). The mortality rate was significantly higher in patients with delirium (46.15% vs 3.70%, p < 0.001) with OR 17.212 (p < 0.001) corrected for age and gender. Delirious patients experienced significantly more complications: cardiovascular (OR 7.72, p < 0.001), pulmonary (OR 8.79, p < 0.001) or septic (OR 3.99, p = 0.029). The odds of mortality in patients with COVID-19 presenting with delirium at any point of hospitalization were seventeen times higher.

Pulmonary Embolism Presenting as Abdominal Pain and Asystole

Pulmonary embolism (PE) is a life-threatening condition that mandates prompt identification and management. The protean and atypical symptomatology of PE can mislead the physician and pose a diagnostic dilemma. Abdominal pain is one such rare symptom that is not commonly encountered in the clinical setting. With the limited availability of literature describing abdominal pain as a symptom of this acute disease, it is pivotal that healthcare workers are aware of this presentation. Herewith, we report a 36-year-old man with no co-morbidities who presented with abdominal pain and subsequent cardiac arrest. He was diagnosed and managed in the emergency department and made a complete recovery.

Risk of psychiatric disorders in pulmonary embolism: a nationwide cohort study

This study aims to investigate the association between pulmonary embolism (PE) and the risk of psychiatric disorders. A total of 21,916 patients aged ≥20 years with PE between January 1, 2000, and December 31, 2015, were selected from the National Health Insurance Research Database of Taiwan, along with 65,748 (1:3) controls matched for sex and age. Cox regression model revealed the crude HR was 1.539 (95% CI 1.481 to 1.599; p<0.001), and after adjusting all the covariates, the adjusted HR was 1.704 (95% CI 1.435 to 1.991, p<0.001), for the risk of psychiatric disorders in the PE cohort. PE was associated with the overall psychiatric disorders, dementia, anxiety, depression, and sleep disorders, after the exclusion of the psychiatric diagnoses in the first year. PE was associated with the overall psychiatric disorders, dementia, anxiety, and depression, after the exclusion of the psychiatric diagnoses in the first 5 years. The patients with PE were associated with psychiatric disorders. This finding could serve as a reminder to the physicians to be more watchful and aware in the long-term follow-up of patients with PE for their care and potential mental health problems.

Massive pulmonary embolism presenting initially as acute psychosis

This is a case of a 68-year-old man with Parkinson’s disease who was admitted in the psychiatry floor for new-onset aggressive behaviour and hallucinations. On the third day of hospitalisation, he suddenly developed dyspnoea followed by an ECG showing atrial fibrillation with rapid ventricular response. A few seconds later, he went into cardiac arrest; he was resuscitated after multiple rounds of Advanced Cardiovascular Life Support. A transthoracic echo showed hypokinetic and enlarged right ventricle. A CT Chest showed a saddle embolus. Patient was provided with systemic thrombolysis, which led to an improvement in his haemodynamic status. Interestingly, his psychotic symptoms also improved. In this paper, we present and review how pulmonary embolism can be associated with acute psychosis.

Acute Pulmonary Embolism: Focus on the Clinical Picture

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.